Strengthening health system responsiveness to citizen feedback in South Africa and Kenya

低收入中等收入国家的公民在公共和私营卫生服务方面遇到一系列问题：从服务质量差到侵犯人权。尽管有许多呼吁和干预措施要求增加社区对保健的参与，但服务使用者和公民往往没有足够的机会与系统接触，了解他们的问题，并提出适当的对策和补救办法。对公民权利和需求的回应是卫生系统的一项基本质量，是提供包容性和负责任的服务、确保公民的社会权利和提高服务质量所必需的。反馈和回应的机制多种多样，导致反馈分散，有时甚至相互冲突。这些措施包括传统的基于设施的投诉箱和出口调查，以及社区报告卡、社会审计和热线等战略。还通过实施卫生设施委员会、跨部门论坛和社区监测系统寻求社区一级的公民反馈。中小岛屿发展中国家越来越多地获得信息技术，往往使公民能够通过社交媒体、主流媒体，甚至通过社会抗议来提出他们的关切。卫生系统反应能力作为卫生系统的一个内在目标，与服务提供结果、财务公平和公平一起，正在获得全球货币。然而，我们目前对卫生系统响应性的了解非常有限，关于公民反馈的结构、实施和有效性以及目前在LMIC中建立的关于卫生服务的相关反应机制，存在着重大的证据差距。在这项研究中，我们旨在通过以下问题来解决这些知识差距：哪些政策和机制(正式和非正式)在接受和回应南非和肯尼亚公民对卫生系统的反馈方面起作用？如何加强卫生系统对发展学习、公平的卫生系统的反应能力？拟议的研究是一项跨学科的混合方法研究，从2018年持续到2020年。这项研究将分三个阶段进行，我们将应用几种主要定性的方法和工具。第一阶段将包括研究省份的政策、反馈机制和系统反应途径的“映射”(以及与反应有关的理论和方法框架)。LMICs中的许多政府都认识到提高卫生系统反应能力的迫切需要，本研究中的两个国家最近都实施了重大政策改革，旨在提高对公民对卫生服务反馈的反应能力。我们将利用这一机会窗口，第二个深入阶段由每个国家的案例研究组成，跟踪这一领域特定创新的实施经验。第三阶段将侧重于知识翻译和跨国比较。该项目将有助于更深入和更系统地了解南非和肯尼亚的卫生系统反应能力，并与其他可比的小岛屿发展中国家相关。通过将嵌入式方法应用于HPSR，该研究也将产生加强卫生系统的效果：为反思实践创造空间，加强系统内的反馈和反应，并改善卫生系统领导人的决策机会。因此，这项关于对公民反馈的响应性的研究也应该提高实施该研究的卫生系统的响应性。在每个国家，我们都与参与实施改革以提高卫生系统反应能力的政策决策者建立了伙伴关系，这项研究将直接帮助改进这些政策。我们还将与其他卫生系统和民间社会领导人接触，以确定加强卫生系统反应能力的战略。

Citizens in LMICs experience a range of problems with public and private health services: from poor quality of services to rights violations. In spite of numerous calls and interventions for increased community participation in health, service users and citizens often do not have adequate opportunities to engage with the system about their problems and induce appropriate responses and remedies. Responsiveness to citizens' rights and needs is an essential quality of health systems, and is necessary in order to provide inclusive and accountable services, ensure the social rights of citizens and improve the quality of services. Mechanisms for feedback and response are varied and result in dispersed and sometimes conflicting feedback. These range from conventional facility-based complaints boxes and exit surveys to strategies such as community report cards, social audits, and hotlines. Citizen feedback at community-level has also been sought by implementing health facility committees, intersectoral forums, and community monitoring systems. Growing access to information technology in LMICs has often empowered citizens to raise their concerns through social media, the mainstream press, and even through social protest. Health system responsiveness is gaining global currency as an intrinsic goal of health systems alongside service delivery outcomes, financial fairness and equity. However our current understanding of health system responsiveness is extremely limited, and there is a significant evidence gap about the structure, implementation and effectiveness of citizen feedback and the related response mechanisms about health services currently in place in LMICs. In this study, we aim to address these knowledge gaps by asking: What policies and mechanisms (formal and informal) work for receiving and responding to citizen feedback on health systems in South Africa and Kenya? How can health systems responsiveness be strengthened towards the development of learning, equitable health systems?The proposed study is an interdisciplinary mixed methods study, running from 2018 to 2020. The study will be conducted in three phases, and we will apply several, primarily qualitative methods and tools. The first phase will consist of 'mapping' of policies, feedback mechanisms and pathways for system responsiveness in the study provinces (as well as theoretical and methodological framing relating to responsiveness). Many governments in LMICs are recognising the pressing need to improve health system responsiveness, and both countries in this study have recently implemented significant policy reforms aimed at improving responsiveness to citizen feedback on health services. We will capitalise on this window of opportunity, with the second in-depth phase consisting of case studies in each country, tracking the implementation experience of a particular innovation in this area. The third phase will focus on knowledge translation and cross-country comparison. This project will contribute to a deeper and more systematic understanding of health system responsiveness in South Africa and Kenya, with relevance for other comparable LMICs. By applying an embedded approach to HPSR, it is intended that the research will also have a health system strengthening effect: creating space for reflective practice, strengthening feedback and response within the system, and improving decision-making opportunities for HS leaders. Therefore, this study on responsiveness to citizen feedback should also improve the responsiveness of the health systems in which it is implemented. In each country, we have partnered with policy decision-makers engaged in implementing reforms for greater health system responsiveness, and this study will directly help bring about improvements in these policies. We will also engage with other health system and civil society leaders to identify strategies to strengthen health system responsiveness.